Managing Pain in the Older Person in the Community

Managing pain in the older person in the community

Item Type Article

Authors Molloy, Niamh

Publisher Nursing in General Practice

Journal Nursing in General Practice

Download date 29/09/2021 05:13:41

Link to Item http://hdl.handle.net/10147/559014

Find this and similar works at - http://www.lenus.ie/hse nursingingeneralpractice clinical review

Managing pain in the older person in the community

NIAMh MOLLOy, PAiN MANAGEMENT NUrSE, UNiVErSiTy HoSPiTAL WATErForD PrESiDENT ELECT iriSH PAiN NUrSES AND MiDWiVES SoCiETy

Introduction acute or chronic, as well as the inferred pathophysiology of pain; Eff ective pain management remains a challenge in modern day nociceptive versus neuropathic or mixed4 or in a clinical context; clinical practice. Managing persistent pain in the older adult en- postsurgical, malignancy related, non malignant, neuropathic counters many challenges and the management of chronic pain or degenerative. Acute pain passes as injury heals while chronic in the community demands a comprehensive understanding of pain persists for three to six months or longer. Neuropathic pain the physiology of pain and pain processing as well as an under- is defi ned as pain arising as a direct consequence of a lesion standing of the various assessment tools available and methods or disease in the somatosensory system.5 Neuropathic pain is to manage pain. it is essential before treating pain that it is associated with disability and reduced quality of life and is often assessed using a recognised pain assessment tool that is valid, underdiagnosed and undertreated.6 older people can experience reliable and comprehensive. in essence, a holistic approach is re- many types of neuropathic pain including peripheral neuropathy, quired with all aspects of the biopsychosocial model considered.1 central post-stroke pain and postherpetic neuralgia.

What is pain? Managing pain in older people Pain is defi ned as an ‘unpleasant sensory and emotional experi- Schofi eld7 suggests a defi nitive prevalence of pain in older peo- ence associated with actual or potential tissue damage or de- ple is impossible to establish. Guidelines for the management of scribed in terms of such damage.2 Pain is also ‘an individual and pain in older adults identifi ed the prevalence of chronic pain in subjective experience modulated by physiological, psychological older people in the community ranged from 25-76 per cent and and environmental factors such as previous events, culture, prog- for those in residential care 83-93 per cent.8 older women have a nosis, coping strategies, fear and anxiety.’3 higher prevalence of pain.8 Pain can be classifi ed according to length of duration; whether The three most common sites of pain in older people are the

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back, leg/knee or hip and other joints.8 Pain may be present in the use of adapted scales for those who have difficulties with more than one location which can cause further disability for the communication. Consider using alternative words for describing patient and social isolation. pain which the patient may associate more closely with such as Older people are at risk of chronic pain due to multiple soreness, hurts or discomfort.18 conditions such as osteoarthritis, diabetic neuropathy, leg ulcers and cancer as well as pain due to surviving cancers. Multi- Assessing pain in cognitive impairment morbidities, which combined with the possibility of reduced Mildly cognitively impaired individuals are almost as able as cognition and sensory impairment, can impact significantly on those without a cognitive impairment to accurately report their level of function and increase disability. pain.19 Individuals with mild forms of dementia are usually able Managing pain in older people is difficult due to the to communicate their pain experience, but this ability is lost presence of multi-morbidities, polypharmacy and sensitivity with more advanced dementia.10 The use of a body chart for the to medications9 as well as potential drug interactions and patient to identify the location of their pain is particularly helpful. drug-disease interactions. Good pain management is essential Pain should be discussed in the present tense using a scale the to support and maintain independent living. Sleep, mobility, patient understands, for example, the Numerical Rating Scale, appetite and mood can be negatively affected by pain while side effects of medications can include anticholinerigic side effects, constipation, nausea and vomiting and the risk of falls. Dewar9 suggests older people may be reluctant to report pain and have a stoic approach, accepting incorrectly that pain is part of the normal aging process. Pain is not a normal part of ageing, but its prevalence increases with age and illness, reaching its highest levels among older people in residential care settings.10 For persistent pain which is resistant to common therapies, Older people may be medications or alternative methods, the health care professional should consider referral to specialist pain clinics.10 In 2005, Schofield et al.11 suggested the need for chronic pain reluctant to report services in the community; in the current climate, this is more evident than ever. In jurisdictions that are moving forward with pain and have a stoic a national strategy for pain (such as Australia), this is already happening; specialist pain teams are moving into the heart of the issue in primary care.12 approach, accepting

Assessment of pain incorrectly that pain A patient’s own report is the most reliable indicator of their pain and when possible this should be obtained.4 A self-report of pain is also possible in those with mild to is part of the normal moderate cognitive impairment with standard assessment tools or if required with more specialised tools such as the Iowa Pain aging process. Thermometer.13 Pain assessment offers patients the opportunity to make a largely subjective experience objective.14 There are multiple assessment tools available to facilitate initial and ongoing assessment of patient pain.15 However, pain assessment is only of value if it is used to guide selection of comprehensive treatments and interventions and to determine the effectiveness of those interventions. Pain assessment must lead to changes Verbal Descriptor Scale or the Iowa Pain Thermometer. The nurse in management and the patient’s pain should be re-evaluated should ensure if assistive devices such as a hearing aid or glasses following these changes to ensure improvements in the are usually required that these are in place.18 (See figure 1: Algo- quality of care.16 The pain assessment tool chosen should be rithm for the assessment of pain in the older person18). Appropri- appropriate to the individual patient taking into consideration ate time should be given for the assessment and be consistent their developmental, cognitive, emotional, language and with the scale used. cultural factors.3 Unidimensional pain scales such as the Numeric Assessing pain in those with cognitive impairment involves Rating Scale, Verbal Descriptor Scale, Iowa Pain Thermometer a three step approach; self-report, caregiver reports and direct although useful, only measure the intensity of pain. Multi- observation.17 In severe cognitive impairment an observational dimensional scales exist and initial assessment would benefit assessment of pain is necessary. During the assessment process from the use of a multi-dimensional tool such as the Short Form it is essential to obtain insight into behaviour from family McGill Pain Questionnaire or the Brief Pain Inventory in the members and carers as a change in behaviour is particularly community.17Subsequent assessment could then be performed important. Stewart et al.17 suggest studies show the Pain with a unidimensional tool as preferred by the patient.12 Assessment Checklist for Seniors with Limited Ability to Nurses should offer assistance with self-report of pain through Communicate (PACSLAC), Abbey Pain Scale and Doloplus-2 as

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the most encouraging scales to use in this patient group. If pain drug-disease interactions. Studies also demonstrate a correlation is suspected, but efforts to assess pain prove difficult, attempt between increasing age and adverse drug reaction.23 an analgesic trial in a structured manner using the World Health While analgesia is safe to use in older people, it should Organisation (WHO) three step analgesic ladder20 and observe be titrated to response8 and age should not be a reason for the patient for effects including side effects.21 withholding treatment.23 Regular administration of simple Updated guidelines on assessing pain in older people are due analgesics such as paracetamol for continuous pain may be to be published shortly by the British Pain Society in conjunction sufficient to reduce pain to a level that allows the person to with the British Geriatric Society. function more independently. The WHO three step analgesic ladder20 originally existed for use with patients with pain Pharmacological management of pain associated with cancer. It is now widely used to manage pain in a Pain is best managed using a multimodal approach, which variety of settings including acute and community care. As pain consists of the use of two or more different classes of analge- severity increases (or decreases), pharmacological management sia targeting different mechanisms of pain.4 8 Optimising pain needs to move up (or down) the ladder utilising stronger (or management is key, but can be difficult in an older population, weaker) analgesics. Adjuvant medications such as neuropathic as such regimes place the older person at risk due to potential agents can be added at any stage of the ladder if there is a altered pharmacodynamics and pharmacokinetics, increasing the neuropathic component to pain. It is imperative to initiate risk of adverse effects,22 toxicity, drug-drug interactions as well as one drug only at a time at a low dose.8 Anti-epileptics, tricyclic

Algorithm for the assessment of pain in older people

Observe for potential indicators of pain: Can the person communicate successfully?* No • facial expressions • verbalisations/vocalisations No immediate treatment needed. Yes • body movements No • altered interpersonal interactions Continue to monitor. • changes in activity patterns of routines Ask whether the person has pain at rest or on • mental status changes movement, use alternative descriptors such as sore, • physiological changes. hurting or aching. Observe for potential indicators of pain. Yes Attempt to interpret meaning Is pain reported / apparent? of behaviour with help of caregivers familiar with the person. Provide individualised Reluctant to Evidence of morbidity care. Yes complain of pain. No that may be causing pain? No Ensure basic comfort needs are met. Assess pain intensity using a simple No immediate Yes Consider providing analgesics scale such as a verbal rating scale or action needed No prior to movement. numeric rating scale. Continue to Treat morbidity. Yes Do potential pain indicators Ask the person to show where their monitor persist? pain is (pointing or pain map). Do potential pain Is pain present? indicators persist?

Yes No Yes No

• Take a detailed pain history. No immediate action Consider empirical No immediate • Examine the patient. needed. analgesic trial or other action needed. • Treat cause. Continue to monitor pain-relieving intervention. Continue to • Treat symptoms if cause is not identifiable. and treat as required. Monitor response carefully. monitor. • Consider referral.

*If there is doubt about ability to communicate, assess and facilitate as indicated in Recommendations 4 and 5 of the Guidelines.

Figure 1: Royal College of Physicians, British Geriatric Society, British Pain Society. The assessment of pain in older people: national guidelines. Concise guidance for practice series no 8: London. RCOP, 2007 18 Source: Concise Guidance To Good Practice. The assessment of pain in older people. National Guidelines (UK).

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transcutaneous electrical nerve stimulation (TENS), acupuncture as well as psychosocial interventions such as mindfulness, self- management programmes and cognitive behavioural therapies can be useful methods to manage and control pain in conjunction with pharmacological methods.27

Non-pharmacological Conclusion Effective pain management requires a comprehensive assessment of the patient to determine the most appropriate method methods play an to manage pain. Careful consideration should be given to the most appropriate assessment tool for the patient. Patients are important and living longer and surviving more serious illnesses with multi- morbidities, many of which are managed in the community. The complexity of patients is ever evolving and it is essential to keep significant role in up with the developments in managing pain. managing pain. References 1. Smith B, Hardman J, Stein A, Colvin L. Managing pain in the non-specialist setting: a new SIGN guideline. British Journal of General Practice. 2014; July: e462-464. 2. International Association for the Study of Pain. [Internet]. 1994 http://www.iasp-pain.org/Taxonomy. 3. Australia and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 3rd Edition. [Internet]. 2010 http://www.anzca. anti-depressants, serotonin-noradrenaline reuptake inhibitors edu.au. and topical lidocaine are recommended first line for treating 4. Pasero C, McCaffrey M. Pain Assessment and Pharmacological neuropathic pain in general.24 Management. St. Louis: Elsevier; 2011. 5. Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Principles of analgesia therapy in older adults Griffin JW, Hansson P, Hughes R, Nurmikko T, Serra J. Redefi- • Perform a full and thorough assessment of the patient’s pain nition of neuropathic pain and a grading system for clinical and involve family members and caregivers if patient self- use: consensus statement on clinical and research diagnostic report is not feasible. criteria. Neurology. 2008;70:1630-1635. • Consider other factors in assessing pain including mental 6. International Association for the Study of Pain. Classification status, mood, beliefs and interpersonal interactions and of Neuropathic Pain. Pain Clinical Updates. [Internet]. 2010 behaviour. September; volume XVIII (7). Available from: http://iasp.files. • Listen carefully to the words used by the patient. The older cms-plus.com/Content/ContentFolders/Publications2/Pain- person may deny pain but admit to discomfort, aching or ClinicalUpdates/Archives/PCU_18-7_final_1390260761555_9. soreness. pdf. • Ask if the patient is taking their medication as advised? Do they 7. Schofield P. Managing chronic pain in older people. Nursing know how to take their analgesia? Do they have any worries or Standard. 2013; 109(30): 26-27. concerns about it? 8. British Geriatric Society. Guidelines for managing pain in • Under treatment of pain can have detrimental effects to the older people. Age and Ageing. 2013; 42: i1-i57. patient clinically 25 and is just as problematic as overtreatment. 9. Dewar A. Assessment and Management of chronic pain in the • Consider the most appropriate method of administration older person living in the community. Australian Journal of of analgesics and be mindful of concurrent medication the Advanced Nursing. 2006; 24(1): 33-38. patient is taking and the potential for drug-drug interactions. 10. The Australian Pain Society. Pain in Residential Aged Care • Be conscious of age related changes to pharmacokinetics and Facilities, Management Strategies. [Internet]. 2005 Available pharmacodynamics. from: http://www.apsoc.org.au. • Start low and go slow, but do not stay low.17Careful monitoring 11. Schofield P, Dunham M, Black C. Older people: Managing may be required and titration performed at a slower pace.25 their pain in the community setting. Journal of Community How much relief have the treatments given in the past 24 Nursing. 2005; 19(9): 24-29. hours? 12. National Pain Strategy. Pain Australia, working to prevent and • Monitor for effects, side effects and adverse reactions. manage pain. National Pain Summit Initiative. [Internet]. 2011 http://www.painaustralia.org.au/images/pain_australia/ Non-pharmacological measures NPS/National%20Pain%20Strategy%202011.pdf. Pharmacological therapy is most effective when combined 13. Herr K, Spratt K F, Garrand L. Evaluation of the Iowa Pain Ther- with non-pharmacological methods.12,26 Non-pharmacological mometer and other selected pain intensity scales in younger methods play an important and significant role in managing and older cohorts using controlled clinical pain: A preliminary pain. There is evidence that physical therapies such as exercise, study. Pain Medicine. 2007; 8(7): 585-600.

30 Butrans A4 (Dec 11)Final:Layout 1 08/12/2011 15:47 Page 1

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Butrans® patches contain an opioid analgesic BuTrans® 5 µg/h, 10 µg/h and 20 µg/h Very common (≥ 1/10) or common (≥ Transdermal Patch. Prescribing 1/100) side-effects: anorexia, confusion, Information. Republic of Ireland. Please depression, insomnia, nervousness, read the Summary of Product headache, dizziness, somnolence, Characteristics before prescribing. paraesthesia, vasodilatation, dyspnoea, Presentation: BuTrans 5 µg/h, 10 µg/h, 20 constipation, dry mouth, nausea, vomiting, µg/h. Transdermal beige patches abdominal pain, diarrhoea, dyspepsia, containing buprenorphine. Indications: sweating, tiredness, pain, peripheral Treatment of non-malignant pain of oedema, application site pruritus, moderate intensity when an opioid is application site reaction, application site necessary for obtaining adequate analgesia. erythema, application site rash, chest pain, BuTrans is not suitable for the treatment of pruritus, erythema, rash, exanthema, acute pain. Dosage and Administration: asthenia. Uncommon but potentially BuTrans should be admin-istered every 7 serious (≤ 1/100): anaphylactic reaction, days. Elderly and adults over 18 years only: anaphylactoid reaction, restlessness, Use the 5 µg/h patch for at least the first 3 agitation, depersonalisation, euphoric days of treatment, before increasing the mood, affect lability, hallucinations, dose if necessary. Do not use more than psychotic disorder, decreased libido, drug two patches at a time. Contra-indications: dependence, mood swings, sedation, ® Known buprenorphine or excipient migraine, balance disorder, speech BuTrans 5mg: hypersensitivity, opioid dependent patients, disorder, blurred vision, visual disturbance, use for narcotic withdrawal treatment, eyelid oedema, vertigo, angina pectoris, 1 respiratory depression, use of MAO palpitations, tachycardia, hypotension, 7 days continuous pain relief inhibitors within the past 2 weeks, circulatory collapse, hypertension, asthma myasthenia gravis, delirium tremens. aggravated, hypoxia, wheezing, Precautions and Warnings: Convulsive hyperventilation, respiratory depression, The lowest dose opioid analgesic patch disorders, head injury, shock, reduced respiratory failure, diverticulitis, dysphagia, 3 consciousness of uncertain origin, ileus, biliary colic, muscular weakness, available in Ireland intracranial lesions or increased intracranial urinary retention, erectile dysfunction, pressure, severe hepatic impairment, sexual dysfunction, oedema, drug history of drug abuse. Not recommended withdrawal syndrome, alanine amino- Reduces the burden of immediately postoperatively or for transeferase increased, accidental injury, 2 situations characterised by a narrow fall. Please consult the SPC for details of daily tablet use therapeutic index or for rapidly varying other side-effects. Legal category: CD analgesic require-ments. May affect ability (Sch2) POM Package quantities: 5 µg/h to drive or use machinery. As with all transdermal patch: 2 individually sealed opioids, chronic use may result in the patches 10 µg/h transdermal patch: 4 development of physical dependence. individually sealed patches 20 µg/h Interactions: Mono-amine oxidase transdermal patch: 4 individually sealed inhibitors (MAOIs), CNS depressants (e.g. patches. Marketing Authorisation benzodiazepines, opioid derivatives, numbers: PA 913/24/1-3. Marketing antidepressants, sedatives, alcohol, Authorisation holder: Mundipharma anxiolytics, neuroleptics, clonidine). CYP Pharmaceuticals Limited, Millbank House, 3A4 inhibitors and inducers, products Arkle Road, Sandyford, Dublin 18. Tel: +353 reducing hepatic blood flow (e.g. (0)1 2063800. One of the Mundipharma / halothane). Pregnancy and lactation: Napp independent associated companies. BuTrans should not be used during Date of preparation: August 2011 pregnancy or in women of childbearing (UK/BUTR-11033). References: 1. Butrans® potential who are not using effective SPC. 2. James IGV, O'Brien CM and contraception. The use of BuTrans during McDonald CJ. J Pain Sympt Manage 2010; lactation should be avoided. Side Effects: 40(2):266-278. 3. MIMS Ireland. A joint effort… good news for your patients Adverse events should be reported to Mundipharma Pharmaceuticals Limited on 1800 991830 and good news for you ® BuTrans and the Mundipharma device (logo) are Registered Trade Marks. © 2011 Mundipharma Pharmaceuticals Limited. IRE/BU-11001 Date of item: September 2011.

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14. Brown D. Pain assessment in the recovery room. Journal of Perioperative Practice. 2008; 18(11): 480-489. 15. McCaff rey M, Pasero C. Pain, Clinical Manual, nd2 Edition. St. MCQS Louis: Mosby; 1999. 16. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd K, Paice J et al. American Pain Society recommendations for im- Q1 Pain can be classifi ed according proving the Quality of Acute and Cancer Pain Management. to: Archives internal Medicine. 2005; 165(14): 1574-1580. 17. Stewart C, Schofi eld P, Gooberman-Hill r, Metha S, Cary reid a) Length of duration M. Managing Pain in older Adults. in: Practical Management b) Pathophysiology of Pain. Benzon H, rathnell J, Wu C, Turk D, Argoff C, Hurley r, c) Clinical context editors. Philadelphia: Mosby; 2014; 467-473e2. d) response to medication 18. royal College of Physicians, British Geriatric Society, British Pain Society. The assessment of pain in older people: national Q2 The most common sites of pain guidelines. Concise guidance for practice series no 8: London. are: rCoP, 2007. 19. Helfand M, Freeman M. Assessment and Management of a) Foot Acute Pain in Adult Medial inpatients: A Systematic review. b) Knee Pain Medicine. 2009; 10(7): 1183-1199. c) Hip 20. World Health organisation. Pain relief Ladder. [internet]. d) Back 1996 http://www.who.int/cancer/palliative/painladder/ en/. Q3 Pain assessment tools include: 21. Galicia-Castillo M, Weiner D. Treatment of persistent pain in older adults. UpToDate. [internet]. 2015 Available from: a) St George’s Questionnaire http://www.uptodate.com/contents/treatment-of-per- b) Geriatric Depression Scale sistent-pain-in-older-adults. c) iowa Pain thermometer 22. Laroche M-L, Charmes J-P, Nouaille y, Picard N, Merle L. is d) McGill Pain Questionnaire inappropriate medication a major cause of adverse drug Q4 In mild cognitive impairment, reactions in the elderly? British Journal Clinical Pharmacology. 2006; 63(2): 177-186. pain assessment should 23. routledge P, o’Mahony M S, Woodhouse K. Adverse drug include: reactions in elderly patients. British Journal Clinical Pharma- cology. 2003; 57(2): 121-126. a) Numeric rating scale 24. international Association for the Study of Pain. Pharma- b) Not using a pain assessment tool cological Management of Neuropathic Pain. Pain Clinical c) Use of a body chart Updates. [internet] 2010 November; volume XViii(9) http:// d) observation iasp.fi les.cms-plus.com/content/contentFolders/Pub- lications2/Painclinicalupdates/archives/Pcu_18-9_fi - Q5 Pain management includes: nal_1390260608342_7.pdf. 25. Chapman S. Managing pain in the older person. Nursing a) The use of 2 – 3 classes of analgesia Standard. 2010; 25(11): 35-39. b) initiating 2 drugs at the same time 26. international Association for the Study of Pain. older People’s c) Not titrating the dose of medication Pain. Pain Clinical Updates. [internet] 2006 June ; volume d) Neuropathic agents can be added at any XiV (3). http://iasp.fi les.cms-plus.com/Content/ContentFold- stage of the pain ladder ers/Publications2/PainClinicalUpdates/Archives/PCU06- 3_1390263667309_19.pdf. Q6 Non-pharmacological 27. Park J, Hughes A. Nonpharmcaological approaches to the measures for pain management management of chronic pain in community dwelling. Journal American Geriatric Society. 2012; 60(3): 555-568. include: a) TENS machine b) Acupuncture

c) Cognitive Behaviour Therapy

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